Provider First Line Business Practice Location Address:
465 MCKENNA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83647-2143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-580-2689
Provider Business Practice Location Address Fax Number:
208-580-9002
Provider Enumeration Date:
04/21/2014